Check if Applicable:

Amended Report
You must also check box of appropriate reporting period

Final ReportZero balance required.PAC must also file Form F-6 Dissolution

Non-Election Cycle Reporting Period:

Annual Report 2010 Calendar Year
Due last Saturday in March or within 6 days thereafter

Report Totals

Fill in totals at the completion of the report.

RECEIPTS OF FUNDS:

Totals for this Period

Contributions

$386.14

Monetary Contributions from all Fund-Raising Events

+$0.00

Receipt of a Transfer of Excess Funds

+$0.00

Total Monetary Contributions:

=$386.14

In-Kind Contributions

+$0.00

Total Contributions:

=$386.14

Other Income

$0.00

Loans Received

+$0.00

Total Other Income:

=$0.00

OUTSTANDING LOANS & DEBTS:

Unpaid Bills

$0.00

Outstanding Loans

+$0.00

Total Debts:

=$0.00

TOTAL CONTRIBUTIONS ELECTION YEAR-TO-DATE (Add total contributions from all reports)

$436.14

CASH BALANCE SUMMARY

Beginning Balance
(ending balance from previous report)

$50.00

Total Monetary Contributions

+$386.14

Total Other Income

+$0.00

Subtotal:

a.

=$436.14

Total Expenditures Paid

$364.60

Total Disbursements of Excess Funds

+$0.00

Repayment of Loans

+$0.00

Subtotal:

b.

=$364.60

Ending Balance:(Subtotal a. - Subtotal b.)*Cannot be negative balance

=$71.54

TOTAL EXPENDITURES ELECTION YEAR-TO-DATE
(Add total expenditures from all reports)

$364.60

Contributions$250.00 or LESS

DATE

CONTRIBUTOR'S FULL NAME OR COMMITTEE'S NAME

AMOUNT

10/18/2010

Robert Hughes

$35.00

10/18/2010

Peter Onoszko

$20.00

10/18/2010

Patricia Rucker

$15.00

10/18/2010

John Cribb

$100.00

10/18/2010

Lynne Deming

$30.00

10/18/2010

Brothers Pizza

$156.14

11/1/2010

Lynne Harty

$30.00

Subtotal of contributions of $250.00 or less

$386.14

Contributions
More than $250.00

DATE

CONTRIBUTOR'S FULL NAME OR COMMITTEE'S NAME

AMOUNT

Subtotal of all contributions of more than $250.00 Subtotal of all contributions of $250 or lessTotal Contributions:

$0.00$386.14$386.14

Other Income: Interest, Refunds, Miscellaneous Receipts

Date

Source of Income

Type of Receipt

Amount

Total Other Income:

$0.00

In-Kind Contributions

Date

Name and Contributor Information

Description of Contribution

Value

Total In-Kind Contributions:

$0

Loans

West Virginia Code: §3-8-5f. Loans to candidates, organizations or persons for election purposes.

"Every candidate, financial agent, person or association of persons or organization advocating or opposing the nomination
or election of any candidate or the passage or defeat of any issue or item to be voted upon may not receive any money or any
other thing of value toward election expenses except from the candidate, his or her spouse or a lending institution. All loans shall
be evidenced by a written agreement executed by the lender, whether the candidate, his or her spouse, or the lending institution.
Such agreement shall state the date and amount of the loan, the terms, including interest and repayment schedule, and a
description of the collateral, if any, and the full names and addresses of all parties to the agreement. A copy of the agreement
shall be filed with the financial statement next required after the loan is executed."

The loan agreement must include all items asked for in the statute. (See above.) The loan agreement does not have to follow a certain format; generally, if all the required information is listed, any format is acceptable. Candidates or political committees that take out a loan for the campaign through a bank or other commercial lending institution must include a copy of the loan agreement executed with that bank or institution. Candidates should not take out loans which are partially for personal use and partially for the campaign. It is almost impossible to keep reporting straight in this case. Any money a candidate contributes to his or her campaign committee with the hope of repayment must be treated as a loan and reported in this section. When a candidate determines that no further repayment can be expected, the loan can be reported as repaid in this section by entering the amount left to repay in the repayments column and reporting the same amount as a contribution from the candidate on Page 2. These loans must be executed in writing. Caution: Candidates may not carry outstanding loans from one campaign to the next. Each campaign is separate. Funds from a current campaign cannot be used to repay a loan from a previous campaign.

How To Report Loans

Each loan for your campaign should be listed on a separate line. (Each time you
loan money to the campaign or get a loan, it is considered to be a separate loan.)
Include the following information ont he form below.

loans(s) from prior reporting periods and the balance of each loan
(Col A.) If a payment was made on the loan, list that in Col. C. Any loan that
was repaid in previous reporting periods does not need to be listed.

new loans, the amount (Col. B), any repayments (Col. C), and the
balance (Col. D.)

Attach a copy of the loan agreement for each loan received during the reporting period.